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Evaluation of Sedation Failure in the Outpatient Oral and Maxillofacial Surgery Clinic Figen Cizmeci Senel, DDS, Phd,* James M

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Evaluation of Sedation Failure in the Outpatient Oral and Maxillofacial Surgery Clinic Figen Cizmeci Senel, DDS, Phd,* James M J Oral Maxillofac Surg 65:645-650, 2007 Evaluation of Sedation Failure in the Outpatient Oral and Maxillofacial Surgery Clinic Figen Cizmeci Senel, DDS, PhD,* James M. Buchanan, Jr, DDS,† Ahmet Can Senel, MD,‡ and George Obeid, DDS§ Purpose: Our goal was to report on the incidence of sedation failures in our outpatient oral surgery clinic. Sedation failure is the inability to complete a procedure under intravenous sedation. There is very little in the oral surgery literature on this subject. Materials and Methods: Proper Institutional Review Board approval was obtained from the appro- priate governing body for this project. The medical records of 539 intravenous sedation patients treated at the Oral and Maxillofacial Surgery Clinic at our institution were retrospectively evaluated to determine the incidence of failed sedation. Patients sedated with midazolam and fentanyl were placed in group A. There were 323 patients in group A. We placed patients sedated with midazolam, fentanyl and methohexital into group B. There were 216 patients in group B. The gender, medical history, type of procedure being performed, amount of drug given, and the patient’s vital signs throughout the proce- dure were recorded. Results: There were 9 failed sedations with a rate of 1.6% (9/539); 3 in group B (1%) and 6 in group A (2%). Five of our failures were undergoing multiple tooth extractions. Two of the failures were undergoing surgical removal of impacted third molars. Two patients underwent mandibular fracture reduction. Failure was attributed to increased agitation and combativeness, uncontrolled hypertension, tachychardia and desaturation. Conclusion: The mandible fracture population and multiple teeth extraction patients had higher rates of failure than other groups. This may be the result of procedure length, type of procedure, or a preoperative anxiety and attitude toward treatment expressed by the patient making sedation unpre- dictable. Level of training and experience of the practitioner may contribute to sedation failure. These results allow us to develop a prospective study protocol of outpatient sedation and to quantify more detailed information about preoperative anxiety, medical status, and social history than we had available during our chart review. More specific conclusions may help us determine if certain patient populations are at a higher risk for failed sedations. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:645-650, 2007 Deep sedation/general anesthesia (DS/GA) is often the inability to continually maintain an airway inde- indicated for the relief of anxiety for outpatient oral pendently or respond purposefully to physical stimu- surgery. DS/GA is defined as an induced state of de- lation or verbal command, and is produced by a pressed consciousness or unconsciousness accompa- pharmacologic or nonpharmacologic method or com- nied by partial loss of protective reflexes, including bination thereof.1,2 In combination with local anes- *Formerly, Research Fellow, Department of Oral and Maxillofa- §Chairman, Department of Oral and Maxillofacial Surgery, Wash- cial Surgery, Washington Hospital Center, Washington, DC; Cur- ington Hospital Center, Washington, DC. rently, Assistant Professor, Department of Oral and Maxillofacial Address correspondence and reprint requests to Dr Cizmeci Surgery, Karadeniz Technical University, Faculty of Dentistry, Senel: Department of Oral and Maxillofacial Surgery, Faculty of Trabzon, Turkey. Dentistry, Karadeniz Technical University, 61080 Trabzon, Turkey; †Former Senior Resident, Department of Oral and Maxillofacial e-mail: [email protected] Surgery, Washington Hospital Center, Washington, DC. © 2007 American Association of Oral and Maxillofacial Surgeons ‡Associate Professor, Department of Anesthesiology and Reani- 0278-2391/07/6504-0009$32.00/0 mation, Karadeniz Technical University, Faculty of Medicine, doi:10.1016/j.joms.2006.06.252 Trabzon, Turkey. 645 646 SEDATION FAILURE IN THE OUTPATIENT OMS CLINIC thesia, it is a safe and effective method of treatment. Table 1. SURGICAL PROCEDURES PERFORMED However, it is not always effective in allowing the physician to complete the planned oral surgical pro- Total cedure. On occasion, a procedure is left unfinished Procedures Patients due to patient combativeness and discomfort in spite Third molar removal 265 of increases in sedative doses. Multiple tooth extraction 157 In a review by Egelhoff et al3 of 6,006 patients Single extraction 31 sedated for diagnostic and invasive procedures, a 1% Implant placement 21 sedation failure rate utilizing different drug regimens Closed reduction of mandible fracture 17 including pentobarbital, chloral hydrate, and other Arch bar removal 13 4 regimens was found. Hoffman et al reviewed multi- Bone graft 8 ple complications encountered during non-anesthesi- Sinus lift 6 ologist-administered sedation and found a 1.35% rate Biopsy 5 of sedation failure out of 960 cases of radiologic pro- Canine exposure 5 Arthrocentesis 4 cedures, emergency department procedures, and in- Excision of cyst 2 5 vasive medical interventions. Slovis et al found a Torus excision 1 failure rate of 1.4% (40 of 2,857). This was a study of Ridge expansion 1 pediatric patients sedated for imaging procedures uti- Alveoplasty 1 lizing a drug regimen of pentobarbital, chloral hy- Soft tissue reconstruction 1 Removal of sialolith from drate, midazolam, diazepam and fentanyl. submandibular duct 1 Mason et al6 looked at sedation failure rates for magnetic resonance imaging and computed tomogra- Senel et al. Sedation Failure in the Outpatient OMS Clinic. J Oral Maxillofac Surg 2007. phy studies of pediatric patients using different drug regimens. He found a 0.6% sedation failure rate using pentobarbital and midazolam; a 1% sedation failure istics of the neck to rule out tracheal deviation, rate using pentobarbital, midazolam and fentanyl; and masses, or other mechanical interferences that would a 3% sedation failure rate using pentobarbital alone. compromise the patient’s ability to breathe under There is very little in the oral and maxillofacial DS/GA. The patients are given clear instructions to surgery literature investigating DS/GA failures. The have nothing to eat or drink after midnight prior to invasive procedures referred to in the above studies their appointment except for their medications; they included central line placement, laceration closure, can be taken with a sip of water. and other less stressful procedures. Our purpose in In group A, the procedures were started with 0.03 to this study was to determine the incidence of failed 0.06 mg/kg midazolam and 1.5 ␮g/kg fentanyl. Two DS/GA in patients undergoing oral and maxillofacial percent lidocaine with 1:100,000 epinephrine was ad- surgery and identify risk factors for failed sedation. ministered to all patients for local anesthesia. According to patients’ responses to local anesthesia administration, body habitus, etc, an additional dose of midazolam in Study Design the range of 0.03 to 0.15 mg/kg was added and then the The medical records of 539 patients treated under procedure was started. It was uncommon to administer DS/GA at the Oral and Maxillofacial Surgery outpa- more than 1.5 ␮g/kg of fentanyl. tient clinic at our institution from December 2000 In group B, the procedures began with 2 to 4 mg of through May 2002 were retrospectively reviewed to midazolam and 100 ␮g fentanyl. A bolus dose of determine the incidence of failures. We separated our methohexital to desired levels of anesthesia in doses patient population into group A and group B. Group of 10 to 15 mg was administered. The total dose of A patients were sedated using intravenous (iv) fenta- methohexital varies from 50 to 200 mg, depending on nyl and midazolam. Group B patients received fenta- patient body habitus, length of procedure, and overall nyl, midazolam, and methohexital. There were 323 response to anesthesia and the procedure being per- patients treated in group A (129 male and 194 female) formed. We used lidocaine 2% with 1:100,000 epi- aged between 12 and 80 years, with a mean age of 46 nephrine to achieve local anesthesia. No patients years. Group B had a total of 216 patients (87 male were converted from group A to group B by adding and 129 female) with an age range between 13 and 55 methohexital to complete a DS/GA. The procedures years, with a mean age of 35 years. were performed by a senior resident who was super- All patients included ASA I–II–III and had no con- vised by a member of the attending staff. traindications to the study medications. Appropriate A summary of the surgical procedures performed is medical consults are obtained when necessary. We shown in Table 1. We defined failed sedation as the also examine the oral airway and physical character- inability to complete the planned procedure. SENEL ET AL 647 Results tion about dental procedures should be assessed when studying patient populations that may fail. A Nine failed DS/GA were found in all patients (1.6%). preoperative dental anxiety level can be evaluated Three of the 9 were in group B (1%) and the other 6 using the Corah Dental Anxiety Scale. This was de- were in group A (2%). DS/GA failures were due to scribed for use in general dentistry and later modified increased levels of agitation and combativeness by the for oral surgical procedures. This is a questionnaire of patient, blood pressure above the level safe to con- the patient’s attitude to certain dental scenarios. A tinue the procedure, paroxysmal ventricular contrac- numerical score is given, based on how the questions tions manifested during the sedation, and paroxysmal are answered, that correlates to a high or low level of ventricular contractions with desaturation. Patients anxiety by the patient toward their oral surgical treat- who failed DS/GA ranged in age from 15 to 54 years ment.13 of age, with a mean age of 28 years. Our patients choose to have their procedures per- Five of 157 (3.18%) patients having multiple teeth formed under DS because they have an increased extracted experienced DS/GA failure.
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